Pressure injury : incidence in critical units of a regional hospital

1 Pressure injury: incidence in critical units of a regional hospital Lesão por pressão: incidência em unidades críticas de um hospital regional Lesión por presión: incidencia en unidades críticas de un hospital regional Stefany Ariadley Martins da Silva1, Patrícia da Silva Pires1, Maiara Pimentel Macedo1, Laudice Santos Oliveira1, Josicélia Estrela Tuy Batista2, Jocélio Matos Amaral1 ORIGINAL ARTICLE


INTRODUCTION
Pressure injuries (PI) are de ned as "localized damage to the underlying skin and/or soft tissues, usually on a bone prominence or related to the use of a medical device or another artifact " 1 .PIs have been highlighted as a public health problem because they are one of the main adverse events related to care in health units and institutions.
The occurrence of PI varies according to the clinical conditions of the individuals and the environment where they are inserted, especially those who need a prolonged period of hospitalization.The mechanism of lesion development is multifactorial and includes intrinsic factors, such as age, comorbidities, nutritional status, hydration, mobility conditions and level of consciousness; and extrinsic, such as pressure, shear, friction, and humidity 2 .
In intensive care units, PIs are a frequent problem.Individuals usually present a severe clinical picture, associated with mobility restriction, loss of muscle mass and a longer period of hospitalization, and are still subjected to multiple therapeutic interventions, and such factors make them more susceptible to the onset of the injury 3 .
Continuous use of certain medications can also lead to the onset and/or progression of the lesion, such as sedatives and analgesics, to reduce pain sensation and impair mobility, and hypotension as it can lead to reduced blood flow, thereby reducing tissue perfusion and making them more susceptible to pressure; in addition, predisposing factors are: general compromised status, age, altered body weight, urinary incontinence, and inadequate care for bedridden or impaired mobility patients, among others 4,5 .
In 2015, the Brazilian Institute for Patient Safety (IBSP) emphasized that risk assessment, skin evaluation and early treatment, mechanical overload (change of position) and use of support surfaces and education for professionals/family and the patient are the guidelines for the prevention of these lesions 6 .
Pressure injury: incidence in critical units of a regional hospital Risk factors for PI development can be identified from the use of scales already validated and used worldwide, being the Braden scale 7 the most applied.It is composed of six subscales: sensory perception, activity, mobility, moisture, nutrition and friction and shear, ranging from six to 23 points and classifying the individual at severe, high, medium or low risk.
In Brazil, there are few investigations on the incidence and prevalence of PI, and punctual studies indicate a high rate of occurrence, especially in the hospital network, with rates varying from 10.62 to 44.1% 8 .There is no data in the national literature regarding the expenses generated by PIs for the healthcare system.International research shows that the treatment of each injury can cost from US$ 2,000 to US$ 30,000, and the annual cost of treating PIs at health facilities can reach US$ 1.3 billion 9 .
Considering the implications for the user and for the institutions, the prevention of LP associated with health care is part of a set of national and international goals, aiming to prevent damages, promote patient safety and qualify the assistance offered in health services 10,11 .
In view of the above, this research arises from the need to identify the extent of the problem and aspects related to PI, considering the high levels of striking and their deleterious effects.This research may alert professionals and managers, as well as direct the actions and services for prevention and control of this iatrogenic event, as well as serve as an evaluation tool for the practices involved in the work process.

OBJECTIVES
To measure the incidence of PI in users hospitalized in critical units of a public reference institution in southwestern Bahia (Brazil).

METHODS
is is a longitudinal prospective study.
The research was carried out in the stabilization room (SR) and in the two intensive care units (ICU) for adults, considered as critical units, of a reference hospital in southwestern Bahia.e SR is one of the sectors that make up the hospital emergency and its structure has six beds, where the assistance is provided by a multi-professional team composed of a nurse, two nursing technicians, a physiotherapist, and the prescribing physician;the two adult ICUs have a total of 18 beds and are attended by two nurses, four nursing technicians, one doctor, and one full-time physiotherapist.Because they are general care units, the pro le of patients is quite variable, including mainly polytraumatized youngsters, adults who are victims of brain vascular events, cancer patients and patients in the postoperative period of major surgeries.

RESULTS
The incidence of PI was 47% (39).Considering the allocation sector, 23.08% (nine) of the participants were in the SR; 20.51% (eight) in ICU I; and 56.41% (22) in ICU II.The mean length of stay in the study was 6.8 days (± 5.5), with a minimum of three and a maximum of 31 days.Pressure injury: incidence in critical units of a regional hospital No participant considered low risk developed PI, and it was not possible to establish a statistical di erence of this variable with the outcome.Regarding the variable protection of bony prominences, no participant was exposed, and it was not possible to establish a relation with the outcome.
Table 3 shows the distribution of PI according to the anatomical location.
e 39 participants who developed PI had a total of 50 lesions.e number of injuries per participant ranged from one to three, with a mean of 1.28 per person.e mean time to onset of the lesion was 5.87 days, with a minimum of three and a maximum of 13 days.

DISCUSSION
The incidence of PI in this investigation was higher than that observed in other studies 3,15,16 .The results point to the association between the use of vasoactive drugs and PI.The justification for such finding lies in the severity of the critical participant, who as a result of hemodynamic instability, may require the use of these drugs as a priority measure to maintain life.Such Regarding the sociodemographic characteristics, there was a predominance of males, which represented 68.6% of the sample.The finding is similar to that of a study conducted in the state of São Paulo (Brazil), in which the majority of participants were male 15 .
Regarding age, the average found in this study was slightly lower than that of other investigations 15,17 .This difference may be related to the profile of the participants attended, considering that the most frequent medical diagnosis was polytrauma, often associated with young individuals.
Most participants were brown or black.It should be noted that the PI stage 1 can be difficult to identify among individuals with dark skin, and this may be an indication of risk, although there are controversies in the literature about these variables 18,19 .
Chronic diseases favor PI development when they a ect sensory perception, circulation, oxygenation, and mobility of participants 20 .When analyzing the presence of comorbidities, no statistically signi cant association was observed.
In this study, it was also verified that the use of continuous sedoanalgesia is associated with PI.These medications may cause decreased sensory perception, decreased mobility and increased friction and shear, these factors predisposing to the appearance of injuries 17,18 .
It Concerning the location of the lesions, the greatest frequency in this investigation was in the calcaneal region, followed by the sacral region, diverging from other studies that point to the sacral region as the most affected 3,9,[16][17][18]21 . Thedevelopment of the lesions probably results from inadequate actions during the handling of the individuals, as well as from the non-observance of the recommendations of preventive measures according to the classification of PI risk by the Braden scale 3,18 .
Staging is an aspect that presents a difference between other studies.Some corroborate with the finding of this investigation in which there is a predominance of stage I lesions 17 , such as the prospective cohort conducted in Espírito Santo, where 72% of LPs were classified in stage I.
Other studies indicate a higher frequency of stage II lesions 3,15,16,22 .It should be noted that the methodology of the present study did not include the follow-up of PI evolution, and it was not possible to know if the lesions progressed to more advanced categories.
The systematic change of decubitus and the use of a mattress with alternating pressure were verified in a restricted number of participants, noting that only one of the units studied has the pneumatic mattress in all the beds.The protection of bony prominences was not verified in any participant, which interferes with the analysis of the data.The aforementioned variables had no significant association in this study.
e sample comprised the universe of eligible patients hospitalized in these units, totaling 83 participants.e inclusion criteria in the study were: age equal to or over than 18 years; the presence of full skin at admission; remain hospitalized in the unit for at least 48 hours; and consent to participate voluntarily in the study or have their participation authorized by the person in charge.Patients considered to be largely burned (burned body surface area above 20%), due to the di culty of evaluating the skin and identi cation of PI were excluded.e collection was carried out for a period of 90 days, between the months of June and August of 2017.Direct interview, medical records, medical prescription and inspection of the participant's skin were used as a data source at the time of admission and, subsequently, during the participation period.e collection was performed by a team of nurses duly trained by the principal investigator.During the period of the research, the participant or his/ her supervisor was approached during the rst 24 hours of admission to the reference units, at the time of the request for consent and inclusion in the study.Consequently, the research form was applied and the first inspection of the skin was performed.Subsequent evaluations occurred on alternate days, respecting the local institutional protocol, and occurred until detection of PI, discharge or death of the participant.e 83 participants were evaluated using a research form developed by the researchers, based on the studies of Bernardes 8 and Costa 12 , being this submitted to a validation pre-test.e instrument consisted of two parts: the rst, which included demographic and clinical data, and the second, which contained questions regarding the data obtained after the participant's skin inspection.For the purposes of PI diagnosis and staging, was used the criteria established by the National Pressure Ulcer Silva SAM; Pires PS; Macedo MP; Oliveira LS; Batista JET; Amaral JM Advisory Panel (NPUAP) (2016).e risk assessment for lesion development was measured using the Braden scale, internationally recognized and validated for the Portuguese language.e demographic data investigated were: age, sex, color, and schooling.Clinicians included previous comorbidities, medical diagnosis, use of invasive devices, use of diet, use of vasoactive drugs and continuous sedoanalgesia, type of mattress used, the record of a systematic change of decubitus and protection of bony prominences.e variables weight and height, when they could not be mentioned, were obtained through the medical record; for body mass index (BMI) was used the recommendation of the World Health Organization (WHO) (1995).In participants whose height could not be reported or was not available in the medical record, it was estimated from the Chumlea formula 13 .Demographic data, diagnoses, and previous comorbidities and record of the systematic change of decubitus were from the medical records to the research instrument every 2 hours.Information regarding pharmacotherapy was obtained on medical prescription.Data were stored in SPSS Statistics 23 software and analyzed in Stata 11 software.The results were described by the mean and standard deviation for continuous variables and absolute and relative frequencies for categorical variables.The association of PI incidence with demographic and clinical variables was made using Student's t-test to compare the quantitative variables; for the nominal qualitative variables, the Pearson's chisquare test was used, adopting p ≤ 0.05 and 95% confi dence interval.The absolute incidence coeffi cient was determined by the number of individuals affected by PI in relation to the total number of participants exposed during the investigation period.The research complies with the provisions of resolution 466/12 and was approved by the Committee for Ethics in Research with Human Beings of the Multidisciplinary Health Institute -Anísio Teixeira Campus -of the Federal University of Bahia (CEP-IMS-CAT-UFBA) under CAAE 64654117.0.0000.5556.

Table 1 .
Sociodemographic characteristics of users of critical units of a regional hospital.Vitória da Conquista, Bahia, Brazil, 2017.
e risk score of the participants performed through the Braden scale revealed that 20.48%(17)of them presented a low risk for the development of PI; 10.85% (nine), moderate risk; 38.55% (32), high risk; and 30.12% (25), severe risk.

Table 2 .
Characteristics related to the clinical condition of users of critical units of a regional hospital.Vitória da Conquista, Bahia, Brazil, 2017.

Table 3 .
Distribution of pressure injuries, according to the anatomical location, in critical units of a regional hospital.Vitória da Conquista, Bahia, Brazil, 2017.